Preview

How to Identify Data in Nursing Field

Good Essays
Open Document
Open Document
587 Words
Grammar
Grammar
Plagiarism
Plagiarism
Writing
Writing
Score
Score
How to Identify Data in Nursing Field
1. The nursing process is the core for the nursing care plan and enables one to think like a nurse. The nursing process is important as it is a systematic problem solving approach which involves the partnership with both the patient and their family. It serves as an important tool to improve practice, quality care and promote good health. The nursing process has four phases include assessment, diagnosis ,planning, implementing, evaluation.
2. One of the components of assessment would be the Chief complaint. the chief complaint is a brief statement of whatever is troubling the patient and the duration of time the problem has existed. The chief complaint is the signs and symptoms causing the patient to seek medical attention. Generally, it is the answer to the question, "What brought you into the hospital (or clinic) today?" If a well person is seeking a routine physical, there is no actual chief complaint
Another component of assessment is the past medical history. This provides background for understanding the patient as a whole and his present illness. It includes childhood illnesses, immunizations, allergies, hospitalizations and serious illnesses, accidents and injuries, medications, and habits.
Family health history. This enhances your understanding of the environment in which the patient lives. Obtaining this information identifies genetic problems, communicable diseases, environmental problems, and interpersonal relationships. Specific inquiry should be made regarding the general state of health of parents, grandparents, siblings, spouse, and children. Record if the patient is adopted and has no access to his biological family's history.
3.In the health history,during this assessment you must interview the patient to obtain a history so that the nursing care plan may be patterned to meet the patient's individual needs. The history should clearly identify the patient's strengths and weaknesses, health risks such as hereditary and environmental factors,

You May Also Find These Documents Helpful

  • Better Essays

    “A guide to taking a patient’s history,” is an article published in Nursing Standard in December 2007, written by Hillary Lloyd and Stephen Craig. The article provides an overview of the process involved in taking a patient history including factors such as; the environment, importance of following a logical order when taking the history, and communication skills.…

    • 1230 Words
    • 5 Pages
    Better Essays
  • Powerful Essays

    Nursing Process

    • 1542 Words
    • 7 Pages

    The nursing process is described as being an individualised problem solving approach in which patients receive nursing care. The nursing process consists of four distinct phases, each having a discreet role in the process, theses phases of the process are: assessment, planning, intervention and evaluation. (Oxford Dictionary of Nursing 2003)…

    • 1542 Words
    • 7 Pages
    Powerful Essays
  • Powerful Essays

    Disclaimer: The focus of this assignment is on communicating details within the written client record. When taking a health history on an actual client, it is essential that the information is accurate. Please inform the person you are interviewing that they do NOT need to disclose information that they wish to keep confidential. If the interviewee decides not to share information, please write, “Does not want to disclose.”…

    • 1111 Words
    • 6 Pages
    Powerful Essays
  • Good Essays

    According to Fruth (2014), “the initial patient interview, also known as the health history or the subjective history, is undeniably the most important component of the patient examination” (p.12). This initial interview acts as a base on which the therapist can perform physical examination and subsequently plan the intervention (Fruth, 2014, p.12). Being a novice, it is important to perform a self-appraisal after completing patient interview. This self-reflection can help to improve patient examination skills and may take the therapist to the expert level (Fruth, 2014, p.5).…

    • 870 Words
    • 4 Pages
    Good Essays
  • Satisfactory Essays

    Family Concept Analysis

    • 307 Words
    • 2 Pages

    On the first contact of a patient, I always ensure I take complete history, this gives me an opportunity of asking questions about family background to elicit family state of health, belief system, status, awareness of health information, relationship etc. Getting these facts not only help me in caring for the patient’s immediate need but also allow me to extend individualized and holistic care. Patients feel a sense of well-being.…

    • 307 Words
    • 2 Pages
    Satisfactory Essays
  • Powerful Essays

    Mrs Deveane Atkinson

    • 1262 Words
    • 6 Pages

    The article by Lloyd, H., & Craig, S. (2007). A guide to taking a patient 's history, appearing in volume 22, issue 13 of the journal Nursing Standard in 2007 explains certain process, approach and procedure in obtaining patients history, emphasizing on the importance of information order collection. This article also expounding on the triage process uses general and non-specific gender, race, or population criteria to obtain the assessment information to treat patients. I plan on summarizing the pros and cons of this article while explaining the author’s process of taking a patients history. In conclusion, incorporating the history taking process using viewpoints of others, while showing key factors that have been excluded.…

    • 1262 Words
    • 6 Pages
    Powerful Essays
  • Better Essays

    Journal Article Review

    • 1671 Words
    • 7 Pages

    In this article, Lloyd and Craig explain how using a systematic approach to taking a patients history can be done precisely and professionally and will gain the most accurate record from the patient. Preparing the environment, communication styles, obtaining consent and history-taking process are the major components in the sequence of questions the patient is asked throughout the interview (Lloyd & Craig, 2007 p. 42-44).…

    • 1671 Words
    • 7 Pages
    Better Essays
  • Satisfactory Essays

    When doing your assessment the first to do is to make sure there is no imminent danger, if so address that first. Then do a systemic assessment. I start and do head to toe. It is important to do a complete past medical history and know any chronic conditions,…

    • 366 Words
    • 2 Pages
    Satisfactory Essays
  • Powerful Essays

    Bipolar Disorder Case Study

    • 2325 Words
    • 10 Pages

    Nursing care plans are then used to document care given and desired outcomes of care for patients (Brown & Edwards 2008). Regular patient assessments are to be undertaken to make sure the nursing care plan still meets their needs. This essay has shown the relevant information required to apply the nursing process framework to develop a comprehensive plan of nursing care Sarah. It includes the nursing assessments, nursing diagnoses, nursing strategies and expected outcomes of the comprehensive nursing care…

    • 2325 Words
    • 10 Pages
    Powerful Essays
  • Good Essays

    assessment with all systems are included as well a full health history . In the review of systems health care professionals obtain answers to a series of questions to identify signs and symptoms which the patient may be experiencing or has experienced. This kind of Information is used to identify the patient problem, assist in the arrival at a diagnosis, identify differential diagnoses, and determine the testing necessary to attain a definitive diagnosis. In a problem focused assessment clinician may give more importance to the ,Chief Complaint (CC)…

    • 210 Words
    • 1 Page
    Good Essays
  • Good Essays

    The nursing process of assessment; planning: intervention and evaluation assists health care professionals with problem solving, and advocates the personal holistic provision of care but at the patient from a holistic view, in order to provide effective care giving (Slevin 2001) then plan and set goals according to the information gathered. The…

    • 1486 Words
    • 6 Pages
    Good Essays
  • Powerful Essays

    To first understand the assessment process I am going to explain the nursing process. This is a vital part of a patients care plan as it is the basis that all health care professionals follow (NICE, 2010). The nursing process consists of 5 stages. These stages are assessment, diagnosis, planning, implementing and evaluation. Assessment is the first stage of the nursing process. For this stage you must collect information about the person, family and their social groups. When asking for information you are looking for the strengths in the person as well as their relationships. When talking about diagnosis, you are looking at the assessment to see any risk, problems within the data or the person’s strengths and groups. Planning is the next stage. This is where you decide the priority of the problems, identify goals within care, select the appropriate interventions and create your plan of care using this knowledge. Giving the care and interventions is the implementation stage. This stage also includes the documentation of the care that is given and maybe any on-going care that is being received by the patient. The evaluation process is the…

    • 3065 Words
    • 13 Pages
    Powerful Essays
  • Satisfactory Essays

    Bloom’s Taxonomy

    • 621 Words
    • 3 Pages

    Something like, which sign or symptom is the nurse likely to assess if the client’s…

    • 621 Words
    • 3 Pages
    Satisfactory Essays
  • Good Essays

    Head to Toe

    • 814 Words
    • 4 Pages

    The head to toe physical assessment is the first step of the nursing process and is a systemic approach of collecting objective (physical) and subjective (mental) data on the patient that will help the nurse formulate nursing diagnoses and plan patient care. It is also used to confirm or question data that was stated in the pt. previous history stated in the charts and to evaluate the effectiveness of the nursing interventions that were carried out on the patient. The main focus of the head-to-toe assessment is to focus on what the patient is currently presenting with; the patient's responses to actual or potential problems.…

    • 814 Words
    • 4 Pages
    Good Essays
  • Good Essays

    while assessing the nature of the patients condition, they try to determine whether the patient has any pre-existing medical conditions.…

    • 579 Words
    • 3 Pages
    Good Essays